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Surrogate Medical Questionnaire

Please be as thorough and detailed as possible when filling out this medical questionnaire. When in doubt, include more information, not less — even if it feels minor or unrelated. Providing complete and accurate details allows us to efficiently collect your medical records and move your screening process forward without delays.

Please do not withhold or minimize any information. Omissions or misrepresentations — intentional or not — can significantly slow down the clearance process and may even impact your eligibility to proceed.

We’re here to advocate for you. The more candid and honest you are, the smoother this process will be for everyone involved.
Thank you for your care and attention to detail.

PERSONAL INFORMATION

Name(Required)

First Middle Last

Date of Birth(Required)

MM slash DD slash YYYY

Phone(Required)

Height(Required)

Current Weight(Required)

Please enter a number from 80 to 300.

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Driver's License(Required)

Please upload a copy of your driver’s license (front and back)

Max. file size: 50 MB.

Social Security Number(Required)

Race/Ethnicity(Required)

Instagram Handle

If Applicable

Twitter Handle

If Applicable

Facebook Link

If applicable (please copy and paste the link to your homepage)

SPOUSE/PARTNER INFORMATION

What is your current relationship status?(Required)

Name of Spouse/Partner

First Middle Last

Spouse/Partner Date of Birth

If single, please skip to PREGNANCY HISTORY

MM slash DD slash YYYY

Spouse/Partner Email

If single, please skip to PREGNANCY HISTORY

Relationship Details(Required)

Please elaborate on your relationship status. Include information regarding dates of marriages, divorces, or separations, as well as length of time in current relationship. If currently single, please elaborate on your relationship with your child(ren)’s other parent.

Do you currently live with your significant other?

If single, please skip to PREGNANCY HISTORY

Yes

No

Has your partner smoked or vaped within the last year?

If single, please skip to PREGNANCY HISTORY

Yes

No

Has your spouse/partner ever been prescribed antidepressants or anti-anxiety medications?

If single, please skip to PREGNANCY HISTORY

Yes

No

Please list which medications, how long your partner used them, or when your partner stopped using them

Has your spouse/partner ever been arrested or convicted of a felony?

If single, please skip to PREGNANCY HISTORY

Yes

No

PREGNANCY HISTORY

Number of Pregnancies

Have any of your pregnancies resulted in multiples?(Required)

No

Yes, my 1st pregnancy

Yes, my 2nd pregnancy

Yes, my 3rd pregnancy

Yes, my 4th pregnancy

Yes, my 5th pregnancy

Number of Miscarriages(Required)

0

1

2

3

4

5

Number of Abortions(Required)

0

1

2

3

4

5

Please give additional information/dates for any and all miscarriages and abortions

Please be as thorough as possible

1st Birth

Date of 1st Birth

MM slash DD slash YYYY

Name of facility or facilities where you received prenatal care(Required)

Name of Hospital/Facility where you gave birth(Required)

City(Required)

State(Required)

Name of Physician

Method of Delivery

Vaginal

C-Section

Weeks of Gestation?

Extreme preterm (<28 weeks)

Very preterm (28–<32 weeks)

Moderate or late preterm (32–<37 weeks)

Full-term (37–41 weeks)

Post-term (42 weeks +)

Additional Information?(Required)

Please explain any issues, complications or anything of note that you may have experienced during this pregnancy. For example: Did you require bedrest at any point during your pregnancy? Did you experience postpartum depression following the birth? Did you use a midwife or doula?

2nd Birth

If you have only given birth on one occasion, please skip ahead to MEDICAL PROVIDER INFORMATION

Date of 2nd Birth

MM slash DD slash YYYY

Name of facility or facilities where you received prenatal care

Name of Hospital/Facility where you gave birth

City

State

Name of Physician

Method of Delivery

Vaginal

C-Section

Weeks of Gestation?

Extreme preterm (<28 weeks)

Very preterm (28–<32 weeks)

Moderate or late preterm (32–<37 weeks)

Full-term (37–41 weeks)

Post-term (42 weeks +)

Additional Information?

Please explain any issues, complications or anything of note that you may have experienced during this pregnancy. For example: Did you require bedrest at any point during your pregnancy? Did you experience postpartum depression following the birth? Did you use a midwife or doula? Was this a surrogacy pregnancy?

3rd Birth

If you have only given birth on two occasions, please skip ahead to MEDICAL PROVIDER INFORMATION

Date of 3rd Birth

MM slash DD slash YYYY

Name of facility or facilities where you received prenatal care

Name of Hospital/Facility where you gave birth

City

State

Name of Physician

Method of Delivery

Vaginal

C-Section

Weeks of Gestation?

Extreme preterm (<28 weeks)

Very preterm (28–<32 weeks)

Moderate or late preterm (32–<37 weeks)

Full-term (37–41 weeks)

Post-term (42 weeks +)

Additional Information?

Please explain any issues, complications or anything of note that you may have experienced during this pregnancy. For example: Did you require bedrest at any point during your pregnancy? Did you experience postpartum depression following the birth? Did you use a midwife or doula? Was this a surrogacy pregnancy?

4th Birth

If you have only given birth on three occasions, please skip ahead to MEDICAL PROVIDER INFORMATION

Date of 4th Birth

MM slash DD slash YYYY

Name of facility or facilities where you received prenatal care

Name of Hospital/Facility where you gave birth

City

State

Name of Physician

Method of Delivery

Vaginal

C-Section

Weeks of Gestation?

Extreme preterm (<28 weeks)

Very preterm (28–<32 weeks)

Moderate or late preterm (32–<37 weeks)

Full-term (37–41 weeks)

Post-term (42 weeks +)

Additional Information?

Please explain any issues, complications or anything of note that you may have experienced during this pregnancy. For example: Did you require bedrest at any point during your pregnancy? Did you experience postpartum depression following the birth? Did you use a midwife or doula? Was this a surrogacy pregnancy?

5th Birth

If you have only given birth on four occasions, please skip ahead to MEDICAL PROVIDER INFORMATION

Date of 4th Birth

MM slash DD slash YYYY

Name of facility or facilities where you received prenatal care

Name of Hospital/Facility where you gave birth

City

State

Name of Physician

Method of Delivery

Vaginal

C-Section

Weeks of Gestation?

Extreme preterm (<28 weeks)

Very preterm (28–<32 weeks)

Moderate or late preterm (32–<37 weeks)

Full-term (37–41 weeks)

Post-term (42 weeks +)

Additional Information?

Please explain any issues, complications or anything of note that you may have experienced during this pregnancy. For example: Did you require bedrest at any point during your pregnancy? Did you experience postpartum depression following the birth? Did you use a midwife or doula? Was this a surrogacy pregnancy?

MEDICAL PROVIDER INFORMATION

Do you visit an OB/GYN for regular women's care?(Required)

Yes

No

Please provide the provider information below

1. Name of Clinic 2. Location of Clinic 3. Approximate dates of treatment 4. Name of Physician (if known)

Do you have a Primary Care Physician (Family Practice Doctor) that you see for routine/regular care?(Required)

Yes

No

Please provide the provider information below

1. Name of Clinic 2. Location of Clinic 3. Approximate dates of treatment 4. Name of Physician (if known)

Have you seen a psychologist or psychiatrist in the last 7 years?(Required)

Yes

No

Please provide the provider information below

1. Name of Clinic 2. Location of Clinic 3. Approximate dates of treatment 4. Name of Physician (if known)

Have you visited Planned Parenthood or any other free clinic for medical assessment or treatment since reaching reproductive age?(Required)

Yes

No

Please provide the provider information below

1. Name of Clinic 2. Location of Clinic 3. Approximate dates of treatment 4. Name of Physician (if known)

Have you had a Pap smear within the last 3 years?(Required)

Yes

No

Please provide the approximate date of your most recent Pap.

Please provide the provider information below

1. Name of Clinic 2. Location of Clinic 3. Approximate dates of treatment 4. Name of Physician (if known)

MEDICAL INFORMATION

What is your blood type?(Required)

What method of birth control are you currently using?(Required)

Do you acknowledge that if you are currently using, or plan to begin using, an IUD, implant, or birth control shot as a means of contraception, it must be removed and/or stopped upon matching. After removal you must experience 2 spontaneous periods before screening can begin at the IVF clinic.

I acknowledge

Breastfeeding?(Required)

Currently Breastfeeding

Quit Breastfeeding less than 2 months ago

Not currently Breastfeeding

Have you smoked or vaped within the last year?(Required)

Yes

No

Have you EVER smoked or vaped while pregnant?(Required)

Yes

No

Please list any surgeries you have had and their dates(Required)

If none, please type “N/A”

Have you ever been immunized for Hepatitis B?(Required)

Yes

No

Have you been fully vaccinated against COVID-19?(Required)

Yes – Moderna

Yes – Pfizer

Yes – Johnson & Johnson

No

Would you be willing to be vaccinated against COVID-19 or willing to receive a booster at the request of the Intended Parents?

Yes

No

Did you ever have postpartum depression?(Required)

Yes

No

Please give more information regarding level of severity and if you received treatment

Have you ever suffered from any type of infertility?

Yes

No

Have you ever been diagnosed with any of the follow?(Required)

Heart Disease

Asthma

Hypothyroidism/Hyperthyroidism

Hepatitis A

Hepatitis B

Hepatitis C

HIV

Herpes

Chlamydia

Gonorrhea

Syphilis

None of the above

For all boxes checked in the previous question, please list approximate dates of diagnosis and treatment

During any of your pregnancies did you ever have any of the following?(Required)

Gestational Diabetes

Placenta Previa

Placental Abruption

Intrauterine Growth Retardation

Blood Clots

None of the above

Have you ever been diagnosed with a Uterine Disorder or Anomaly such as septum, fibroids or polyps(Required)

Yes

No

If you have previously been a surrogate please provider IVF provider information

1. Name of IVF Clinic(s) 2. Location of IVF Clinic(s) 3. Name of IVF Physician(s) 4. Name of Former Agency (if applicable)

Are you okay administering self injectable hormones?(Required)

Not always required, but necessary in many cases.

Yes

No

Have you been COVID vaccinated? If so, which vaccine? If not, would you get vaccinated at the request of the intended parents?(Required)

THANK YOU! PLEASE CLICK "SUBMIT" TO COMPLETE YOUR MEDICAL QUESTIONNAIRE AND MOVE ON TO THE MATCHING QUESTIONNAIRE.

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